From Optumized: “Re: Optum’s acquisition of Humedica. Confirmed by Lazard Capital Markets.” I appreciate that the update from Steven Halper, managing director of equity research, credited HIStalk as the original source (as I, in turn, should thank Embers and another couple of readers who tipped me off). A Boston Business Journalarticle says the acquisition is valued by an insider in the hundreds of million dollars. I interviewed Humedica President and CEO Michael Weintraub a year ago. I notice that the Boston paper is getting credit for breaking the news with its Friday afternoon article even though I ran and confirmed it Tuesday evening with the help of readers.

From False Positive: “Re: Farzad’s rebuttal that talks about ‘cynical critics.’ Who are they? How does he know that they don’t like paper?” The cynical critics, at least those constantly seeking attention, are easy to spot because they sing only one loud and sustained note. When I read an emotional, overwrought restaurant review on Yelp, I always click that person’s profile to see if they have a mix of positive and negative reviews and ignore them if not. Likewise, I twit filter the monotonic EMR whiners and cheerleaders alike, placing a lot more value on the 80 percent who don’t flaunt their blinders publicly. Farzad was right about the RAND study – they said their original projections about EMR savings were wrong because EMR adoption was less than expected and payment incentives are still screwed up. The job of EMRs is to support reform, not to create it. He’s also right that those cynical critics haven’t written smug and pedantic articles extolling the virtues of paper medical records, so they’re leaving us to breathlessly anticipate their suggested alternative. And if they’re intentionally avoiding EMR-using doctors and hospitals for their own care, they aren’t blowing that horn either. What they should be criticizing is the healthcare system that created the current batch of EMRs that conform precisely to its ridiculousness.

From The PACS Designer: “Re: TPD’s List. The recent update of TPD’s List of iPhone Apps that added a HIStalk Sponsors section has created new interest amongst them to recognize their iPhone apps. Vitera informed us about an app (above) that provides healthcare providers access to their Intergy EHR solution enabling anytime, anywhere access to schedules, tasks, patient records, and e-prescribing. Humetrix alerted us to several iBlueButton apps they developed with HHS. These new apps will be added to the next TPD’s List update.”

From Ear-Ground Continuum: “Re: MEDecision. Huge downsizing – they let 83 people go last month with another round this week and next.” Unverified. Recent comments on Glassdoor are certainly interesting. UPDATE: Verified by a reader’s link.

Speaking of the RAND study, more readers think it was naïve rather than biased (and yes, RAND should be capitalized, at least if you buy the idea that it’s OK to make up acronyms solely to create a conveniently pronounceable word, in this case Research ANd Development.) Anyway, new poll to your right: if you had to buy a vendor’s stock, which of the five listed would you choose?

Several readers (me included) expressed an interest in hearing more from Robert D. Lafsky, MD, whose guest articles always contain an impressive mix of medical knowledge, wry cynicism, and grammatical excellence (he always e-mails me when he finds my mistakes, and the threat of incurring his gentle wrath caused me to double-check the spelling of RAND). He has agreed to elevation to regular contributor under the nameplate The Skeptical Convert, with his first installment running this weekend.

Here’s a new Spotify playlist of what I’m listening to: new Aaron Neville, The Cardigans, 4 Non Blondes, Alabama Shakes, Imperial Teen, and a few more.

Welcome to new HIStalk Platinum sponsor The McHenry Group, an executive search firm focused entirely on the healthcare software and services vendor market. TMG’s team of search consultants averages more than 11 years with the company, having placed over 2,000 candidates since 1991. TMG has developed the industry’s largest candidate database of hard-to-find talent, including the hidden candidate market. The company conducts videoconference interviews with every candidate and forwards the videos of the strongest to the client for their review which moves things along faster and gives a better fit, enabling TMG to offer an extra-long 12-month replacement guarantee. TMG has filled positions for CEO, COO, CMO, CMIO, SVP, business development, sales VP, and informatics roles for companies such as RelayHealth, McKesson, Orion Health, and Health Language. They have conducted searches across the entire US as well as for non-US companies building their US operations. Featured business development stars are experts in clinical software, Meaningful Use, and payor technology, while project manager and implementation candidates are available in EMR, multi-hospital implementations, and client services. TMG provides well-screened candidates, ethical search consultants, and a promise to understand the client’s business needs. Thanks to The McHenry Group for supporting HIStalk.

Athenahealth files notice with the State of Alabama that it will lay off 36 employees at its Birmingham office on March 6. The company has not announced what types of workers are affected, although Birmingham was the location of Proxsys, the care coordination systems vendor athenahealth acquired in 2011 to boost its athenaCoordinator product.

Compuware turns down the $2.3 billion buyout offer of Elliott Management Corp and says it will instead spin off Covisint as originally planned.

Weird News Andy says this is better than die-alysis. A kidney patient in China who can’t afford dialysis treatments has lived for 13 years so far by dialyzing himself three times each week using a machine he built from kitchen tools and old medical equipment. He recently declined the Chinese government’s offer of free dialysis that was extended after his story was picked up worldwide, saying the hospitals are too far away and too crowded. He’s not worried that two of his friends died after trying a similar setup.

WNA also likes the RP-VITA iPad-controlled medical robot that just received FDA approval.

Farzad Mostashari can bask in the knowledge that he’s a big enough name to be featured in a CAP News parody (it’s like The Onion, but not as well done). I think they probably chose him randomly for the article Toilet Sizes Expand to Meet Needs of Obese Nation, quoting him in describing a new HHS standard called “Ass Cheek/Toilet Seat Ratio.”

Gartner says Big Data has reached the Trough of Disillusionment stage of its ingenious Hype Cycle, of which I’ve been a long-time fan. If the author is correct – and I would say she is – the previously Big Data-fawning press will start running negative articles, which is OK since once that negativity has been purged, it’s on to the Trough of Enlightenment, where organizations whose interest is more than fad-chasing start delivering results. A Wall Street Journal blog post on the Gartner item quotes Aurelia Boyer, CIO of New York Presbyterian Hospital, who says they’re using Hadoop with natural language processing to analyze millions of patient records to find, for example, how many of them have mentioned a gunshot wound.

A study looks at why patients may think doctors who use clinical decision support are less capable. Apparently patients worry more about doctors using non-human tools rather than having a doctor who seeks external advice.

New Hanover Regional Medical Center (NC) goes to paper downtime procedures for seven hours Thursday when its Epic system goes offline due to an AT&T regional outage.

An online publication HITECH article elicited interesting comments. Granted some of them veer into death panel nut job territory, but they’re still fun to read and some are insightful.

“EMRs encourage doctors and nurses to cheat and lie. EMRs have made medical records inaccurate and unreliable. When I read medical records nowadays, I often can’t tell what the hell happened.”

“In an EMR, every URI is an average URI.”

On the use of surgical case templates: “… worked out with the hospital risk management department to describe what should happen, and entered in the EMR with one click of a mouse. What actually happened? No one can tell.”

“The response calling this idiocy a step in the right direction apparently fails to get the point, which is that EMRs make crappy doctors look like decent ones by giving them the same well-written notes as the good ones.”

“It seems to me that this isn’t exactly the unintended consequences of EMR; it’s the unintended consequences of the government incentivizing bad EMR by incentivizing the wrong things: the ACA encourages rapid adoption of immature or awkward technologies without clear benefits; medicare, medicaid, ACA, and the employer-provided health insurance tax exemption incentivize egregious billing practices. EMR and provider companies respond to the incentives; the problem isn’t the software per se, but the incentives. There’s no inherent reason why an EMR system should require more data entry on the part of doctors, or why the data entry should take longer than updating a paper chart. Systems could be designed that work better and provide consumer benefits, but they aren’t appearing because the system incentives really aren’t designed to serve the customer.

A physician on not customizing template-created notes: “I like to think most of us are pretty honest, and this doesn’t feel like a lie, more like the best that can be done with the time available and the limits of the EMR. I don’t know if I am only humoring myself about the honesty. I do know the job can’t be done except by the copy and paste method.”

“This article misses a key point. If they’re fine falsifying electronic records, why wouldn’t they be comfortable falsifying written records? Moreover, electronic records are easier to falsify, but they’re also easier to catch.”

“I think physician associations need to reemphasize that documentation by exception is not appropriate for physicians, perhaps even take it a step farther and officially declare it outside the standard of practice. The great potential benefit of EMR’s (along with the requirement that they be able to produce data in a standard format) is that medical charting will stop being primarily about stories and start being primarily about data. This will not only make treatment of patients more scientific, it will energize evidence-based medicine. Right now, about half of medical treatment is done despite no evidence of efficacy. Of course, if the data is unreliable, we have GIGO. So the use of charting by exception leading to bad data is a huge problem.”

“EMR’s are the vehicle for corporate and government direction of medical care. I predict that within 5 years, it will be illegal to provide medical care to a patient unless it is through an Electronic Medical Record … this idea will be advanced as important to preventing waste, fraud and abuse.”

“Simply put, doing a thing, and documenting the doing of a thing, are two separate, and not particularity related skills (I would figure that journalists would understand this better than anyone), and it is unlikely that a person who is good at the former is also good at the latter, and when we ask him to do both, this is what we get. Cheer up, we could get the people who do amazingly good documentation to do the surgery. I suspect that would be much worse.”

I’m scooping Weird News Andy on this story: a drunken Englishman is hospitalized after the paramedics he called found his frigid sexual partner dismembered in a snowy field. The partner was a snowman; the man’s injury involved frostbite of his manhood, which nearly required amputation.

It’s NextGen Part 3 from Vince this week as he covers Opus Healthcare Solutions.

Sponsor Updates

SimplifyMD is running cartoons and videos looking at the humorous side of medical practice at “Easy Street Family Practice.”

Nuance announces that the electronic medical records systems used by hospitals and clinics in the United Arab Emirates will be voice-enabled using Dragon Medical.

Further, Farzad states “But the article misses the critical point that the key to taming health care costs is to change the way we pay for care so that we reward outcomes, value and better care coordination. All of these reforms require electronic health records to carry out. ”

What is his evidence for that assertion? Maybe electronic health records cannot accomplish those goals. Maybe electronic health records can only make things worse.

Where is the irrefutable, unchallenged evidence that EHR’s are essential to “improving outcomes, value and better care coordination”?

The evidence to date spells a very different picture, and saying it’s because we ‘need new versions’ or anything similar is pure speculation.

The letter by Farzad M., the ONC chief, ignores the point of the recent RAND report, that the savings are just not there, no matter how hard you squeeze the data. The critics, and I am rapidly becoming one of them, are correct to refute the unsubstantiated claims that HIT is safe, that outcomes improve, and that costs go down. Those claims by Farzad M. and the ONC are simply not proven. A well organized paper chart lends itself well to the clinical detective work that doctors and nurses do with one caveat, that being that lab data and images are best presented electronically.

Would I go back to paper? Yes, for certain components to enable my team of nurses and doctors to figure out the most complex of cases. Something is missing when we review cases on the EMR that creates impediments for effective clinicians.

“But the article misses the critical point that the key to taming health care costs is to change the way we pay for care so that we reward outcomes, value and better care coordination. All of these reforms require electronic health records to carry out. ”

The problem is that the EHRs that are being implemented as a result of HITECH and cheerleaded by Farzad and ONC aren’t the ones that will support the needed reforms. Just the opposite, in many cases and many implementations. Put another way, % EHR (EMR) adoption (or MU attestation, qualification, amount paid) aren’t good surrogates for improved outcomes, lower costs or better care coordination.

Another key issue is the inconsistent quality of EHR products and the inconsistent quality of their implementations. Simply put, for every company that conducts rigorous QA, representative usability testing and other ways to ensure that the product will function in an error free manner, there are probably an equal number that don’t do any of these things. Same with implementations. This is something that ONC ignored until very recently and only at the urging of the IOM. There is no oversight. No transparency. No systematic evaluation or learning that’s going on. Despite the investment of billions. And that’s a huge shame.

ONC has a tough job but the kind of defensiveness that’s being displayed in responses like Farzad’s doesn’t lend to his credibility. Unfortunately, the money has largely been spent, the promises long ago made, the (not interoperable) systems already bought and partially implemented…and here were are.

Re: RAND Study
As one who has worked as a health provider CFO and CIO, systems developer/vendor, and health care consultant for over forty years I am not surprised Rand came to its current conclusion – EMRs have not reduced health care costs. I was really surprised when in 2005 they said EMRs could save $80bill a year.
In all my years of health care experience I have NEVER seen a capital investment in healthcare/medicine actually save dollars when you take a total health system view.
Think about it. Back in the 60’s most lab procedures were done manually. So for better quality and efficiency we invented lab auto analyzers, they could do 2 to 4 chemistry tests all at once. In the 70’s it went up to 20 tests, in the 90’s it went up to 50 and they could be done on a ‘discreet’ basis meaning you could pick and choose which test to run. Was all this more efficient? You bet it was. Was it better quality health care? Of course it was, and better quality (and quantity) generated far more medical information and identified many previously hidden patient medical problems. And finding more medical problems meant more health /medical care was needed.
The same can be said for Radiology, first simple Xrays, then CAT scans, next PET scans, now NMR, and so on. By the way, when CATs were introduced I the late 70s I was a CFO at a major teaching hospital. As we evaluated whether to spend a half million dollars for one unit we were told by our Radiologists that if we bought a CAT scanner we could stop buying regular Xray machines. Never happened. Were the these advances in imaging more efficient, yes, better quality health care, yes, and as with the better lab analyzers more patient medical problems were identified. In short, better diagnostic tools mean you will always find more patient medical problems, which in turn demands more therapies, and more specialized procedures, more specialists, and even more sophisticated tools.
Add to that an aging patient population, more chronic illnesses, and societal issues such as drug abuse, smoking, and obesity and the cost picture looks even worse.
What we seem to forget (or ignore) is that health and medical care is not a zero sum game. We have absolutely no idea how many medical problems are out there. The human body is far too complex and when you came into this world your parents were not handed a human maintenance manual, or a trouble shooting guide. For over a thousand years, primarily using trial and error, we have been struggling to ‘reverse engineer’ the human body, trying to identify all the possible failure points. Yet it seems for every problem we do identify with our expensive tools, we find three more. All these wonderful medical devices have taken us deep into human biology but we still could fill the oceans with what we don’t know.

Looking at overall health expenditures and expecting EMRs to reduce it is like believing that the new set of socket wrenchs you just bought is all you’ll need to fix your car. EMRs are no more than tool and a relatively simple one at that.

I do not understand what Farzad is trying to say. Is he defending HIT expense and criticizing the critics because they, in his impression, will not use paper? That does not make using HIT that is expensive and of unproven cost effectiveness the best systems for managing patients and their safety.

I understood why HCSC bought MEDecision in ’08. HCSC was quite concerned about the future prospects of what was a key piece of software for them & about the future prospects of a company that began to flounder under the scrutiny of being publicly-traded.

It was a company that once sold a decent-enough product but to a very limited base (BCBS plans and mid-sized plans) and was heavily dependent on just 3-4 key clients for a huge chunk of their revenues. Still hasn’t changed and the biggest problem is that the mid-sized health plans who were a potential key potential source of business have largely dried up for several reasons (e.g., M&A, decreasing commercial enrollment, etc). There is also a huge challenge in trying to getting a health plan to fully-convert over to the MEDecision solution too.

Things have just been compounded by the fact that MEDecision has made several strategic errors or mistakes too since ARRA was passed including buying HX Technologies as their HIE platform and some of their continued ‘payer-to-provider’ outreach efforts.

MEDecision will stay around in some format simply because HCSC can’t and won’t let them fold along with a few other Blues plans including BCBS of Florida). I don’t see how they are positioned moving ahead forward to really remain a viable business that has strong growth prospects externally by .

adding a new number of new clients though. The only real prospect of growth for them is if they somehow make their solution affordable and palpable to some of the new hospital-owned health plans that are reemerging.

The critics are growing in number. Whether they will go back to paper is not supportive of your position. I am confused by your position. Critics are gagged by the hospitals for if they complain, they get sham peer reviewed and threatened and in some cases, suffer frank retaliation with charges of “disruptive behavior”.

I know plenty who will go back to paper as it was before electronics, and there are many dead and maimed patients who would prefer that too. I am not saying that the digital availablility of results is not desired, but the CPOE devices and CDS devices are horrific.

The clinical effectiveness of doctors has suffered with the advent of EHR, CPOE and CDS because of innumerable reasons including poor usability, unavailability when needed, interface failures, hidden and lost data, and delays in care.

You can not tell me that the patients in the hospital in NC that lost all records when ATT went down did not experience adverse events from the delays in care, that could take days to manifest themselves. Those adminstrative PR comments and touchy feely defenses are nothing but hogwash.

What does HIMSS have to say about this report? Answer: probably nothing, that is why they did away with Patient Safety as a Domain of interest- they realized safety was Officially excluded as a concern in part through their own efforts to lobby against it while pretending it was an issue. The reality of the game is shame- plenty of that to go around.

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